The Latent Phase: Mind the Gap

By Stephanie Tillman, CNM, MSN

Wondering
what final experiences to squeeze in before being sent out on your own? Here’s
a starter list of opportunities to ask your instructors and mentors for so it’s
easier for you to bridge the gap between student and independent provider.

In my
final months of midwifery training, I decided I needed to step up my game. I
couldn’t quite put my finger on what they were, but I knew there must be a few
hidden gaps in the transition from advanced student to practicing clinician –
gaps that stretched beyond learning the evidence and memorizing facts. In my first
few months of independent practice, those gaps became glaringly self-evident in
the overwhelming sense of responsibility I felt. I now apologized to women when
I ran late in the clinic, held the full weight of explaining my chosen
management plan to a disagreeing collaborative provider, and decided how to
discuss results over the phone. As a student, the full circle never stopped and
ended with me; the full responsibility of patient care was never my own. I knew
that when in a tight spot, I could look over my shoulder to the preceptor, and
that midwife would speak up and clarify or do damage control as needed.

It
would have been helpful to test out the weight of that responsibility, even
partially, while still within the embrace of an instructing or orienting
midwife. Holding myself solely accountable, to a degree, for the beginning and
end of conversations, or encounters, or arguments, would have introduced me to
the idea that not only do you memorize everything, but there’s also the difficult
social component of this work, and you have to do that, too. Take a few deep
breaths: there’s still time!

For
those of you in the last year of midwifery school or who are completing
orientation at a new employer right now, here are some suggestions of tougher
day-to-day activities to experience while still within arms’ reach of
knowledgeable midwives:

Run an entire clinic day on your own.

From
start to finish: see all of the patients, order all of the labs, run late and
apologize to everyone, ask support staff or collaborative providers for help
when needed, apologize for running late again, eat lunch while charting, handle
the emotion of walking from a sad room immediately into a happy one, return
messages, complete refill requests, and call with lab results. Of course you’ll
need your supervising midwife to participate, but find a way for an entire day
of responsibility to feel mostly yours.

Consult with collaborative physicians.

This
part of midwifery can be the most trying, the most delicate, and at times the
most infuriating. To leave a conversation with a collaborator and feel success
and happiness or frustration and anger is to have been a midwife. Be the main
communicator with a collaborator as often as possible while still able to defer
to another midwife, and stretch your comfort zone with consultations.

Sign-out at rounds.

Own
up to how you managed patients during the day when signing off to the night
team. Depending on the setting you might work in, this could be easy or tough.
Get your practice in now.

Find language to communicate with colleagues who disagree with
your plan.

This applies
to all colleagues, including nurses and medical assistants and office managers.
Midwives do things a bit differently, and not everyone has worked with a
midwife before, so the spectrum of different care can cause immediate “no’s”
before “yes’s.” This can be as easy as “I prefer her to stay dressed while
doing the history,” and as complicated as “Women under my care can eat and
drink during labor.”

Consult with other colleagues.

Call
ultrasound and ask what they meant on their report. Knock on the Family
Physician’s office to ask a primary health question. Call the nurse in
Antepartum Testing to ask what is typically done and what she would suggest.

Interpret lab results, and call patients about them.

This
is the antithesis of care at times: seeing a client for something that’s not
immediately clinically straightforward, and adding up the lab results into a
diagnosis. In the classroom, numbers can seem to point to a clear diagnosis,
but that is often not the case in the clinic. Interpreting values and informing
patients of them requires practice.

I
asked readers through my Feminist Midwife Facebook page to add
their own items to this list, and their suggestions were great! Anything GYN
related, delegating tasks, billing and coding, ordering the right lab tests,
and appropriate language for referrals were all mentioned. All tricky and
important things to learn!

There
are moments that you might never feel prepared to handle, regardless of
practice. Like when fetal heart tones cannot be found. When a biopsy tests
positive for breast cancer. With a reactive HIV test. When an emergency
cesarean is truly an emergency. Find the language for these as well, so that
when emotions are involved you have a repository from which to pull.

There
are gaps between training and practice that call for more preparation and
support. This is a starter list. Allow midwifery preceptors and orienters to
“midwife” you through these final moments. These situations can be difficult,
but with practice and support, they are surmountable.

Are
you a midwife in the first year of practice with suggestions for what students
and preceptors should focus on in the final months of training? Please add your
suggestions to the list in the comments below!

Stephanie Tillman is a
recently-graduated nurse-midwife now practicing full-scope midwifery in the
urban United States, at a Federally Qualified Health Center (FQHC) and as a
member of the National Health Service Corps (NHSC). With a background in global
health and experience in international clinical care, the impact of public
health and the broader profession of midwifery are present in all her thoughts
and works. Stephanie's blog, Feminist
Midwife, discusses issues related to women, health, and care. Find out
more at www.feministmidwife.com and follow her on Twitter at @feministmidwife.

Any opinions expressed in this blog are those of the individual participant(s) and do not necessarily reflect the views of the American College of Nurse-Midwives. ACNM is not responsible for accuracy of any of the information provided by guest bloggers and/or members via the Comments section. We welcome all feedback – including comments, ideas and suggestions. We also welcome civil, friendly debates. However, any and all content that is deemed inflammatory or rude will not be posted.